MEDICALGRAND ROUNDS

Department of Medicine

Burnout in Healthcare:An Overview and Framework for Solutions

October 23, 2017Presenter:

Colin P. West, MD, PhDProfessor of Medicine, Medical Education, and Biostatistics

Division of General Internal MedicineDivision of Biomedical Statistics and Informatics

Mayo Clinic

Financial Disclosures• None

Objectives

• Discuss the scope of the problem of physician burnout.• Describe contributors to and consequences of physician burnout and

distress. • Discuss evidence-based methods to prevent burnout and promote

physician wellbeing.

Objectives

• Discuss the scope of the problem of physician burnout.• Describe contributors to and consequences of physician burnout and

distress. • Discuss evidence-based methods to prevent burnout and promote

physician wellbeing.

What is Burnout?

Burnout is a syndrome of depersonalization, emotional

exhaustion, and low personal accomplishment leading

to decreased effectiveness at work.

Depersonalization

“I’ve become more callous toward people since I took this job.”

Emotional Exhaustion

“I feel like I’m at the end of my rope.”

Matriculating medical students have lower distress than age-similar college graduates

2012, 7 U.S. medical schools & population sample (slide from Dyrbye)

Brazeau et al. Acad Med. 2014;89:1520-5

What happens to distress relative to population after beginning medical school?

Burnout among ResidentsNational Data (West et al., JAMA 2011)

Internal medicine residents, 2008 SurveyBurnout: 51.5%Emotional exhaustion: 45.8%Depersonalization: 28.9%

Dissatisfied with work-life balance: 32.9%

Burnout among Practicing PhysiciansNational Data (Shanafelt et al., Arch Intern Med 2012;

Mayo Clin Proc 2015)2011 2014

Burnout: 45.8% 54.4%Emotional exhaustion: 37.9% 46.9%Depersonalization: 29.4% 34.6%

Dissatisfied with work-life balance: 36.9%, 44.5%

Figure 1

Mayo Clinic Proceedings 2015 90, 1600-1613DOI: (10.1016/j.mayocp.2015.08.023) Copyright © 2015 Mayo Foundation for Medical Education and Research Terms and Conditions

Demographics of BurnoutMore common for:

WomenYounger doctors“Front line” specialtiesGreater number of work hours per weekPrivate practiceIncentive-based salary structure

But Don’t Burnout and Distress Affect Everyone?

2014 AMA SurveyEmployed Physicians vs. Employed U.S. Population

Physiciansn=5313

Population n=5392

p

Male 62% 54% <0.001

Age (median) 53 52 <0.001

Hrs/Wk (median) 50 40 <0.001

Burnout* 49% 28% <0.001

Dissatisfied WLB 49% 20% <0.001

* As assessed using the single-item measures for emotional exhaustion and depersonalization adapted from the full MBI. Area under the ROC curve for the EE and DP single items relative to that of their respective full MBI domain score in previous studies were 0.94 and 0.93

Shanafelt et al., Mayo Clin Proc 2015

2011 AMA Survey• Adjusting for:

• Age, gender, relationship status, hours worked/week, education

• Education (ref. high school graduates): • Bachelors degree: OR=0.8• Masters degree: OR=0.71• Doctorate or non-MD/DO professional degree: OR=0.6• MD/DO: OR=1.36

Shanafelt et al., Arch Intern Med 2012

Objectives

• Discuss the scope of the problem of physician burnout.• Describe contributors to and consequences of physician burnout

and distress. • Discuss evidence-based methods to prevent burnout and promote

physician wellbeing.

Are physicians at inherent risk?The “Physician Personality”

TRIAD OF COMPULSIVENESSDoubt

Guilt Exaggerated Sense

ResponsibilityGabbard JAMA 254:2926

The “Physician Personality”Adaptive

• Diagnostic rigor• Thoroughness• Commitment to patients• Desire to stay current• Recognize responsibility of

patients’ trust

Maladaptive• Difficulty relaxing• Problem allocating time for

family• Sense responsibility beyond

what you control• Sense “not doing enough”• Difficulty setting limits• Confusion of selfishness vs.

healthy self-interest• Difficulty taking time off

Gabbard JAMA 254:2926

Physician Distress: Key Drivers

• Excessive workload

• Inefficient work environment, inadequate support

• Problems with work-home integration

• Loss autonomy/flexibility/control

• Loss of values and meaning in work

Consequences of Physician Burnout• Medical errors1-3

• Impaired professionalism4-6

• Reduced patient satisfaction7

• Staff turnover and reduced hours8,12

• Depression and suicidal ideation9,10

• Motor vehicle crashes and near-misses11

1JAMA 296:1071, 2JAMA 304:1173, 3JAMA 302:1294, 4Annals IM 136:358, 5Annals Surg 251:995, 6JAMA 306:952, 7Health Psych 12:93, 8JACS 212:421, 9Annals IM 149:334, 10Arch Surg 146:54, 11Mayo Clin Proc 2012, 12Mayo Clin Proc 2016

Breaking News!

• A new illness runs rampant in our communities!• Affects 54% of certain parts of the population, a

risk 2x that of the rest of the population!• ~500,000 people• Prevalence comparable to that of lung cancer

• Affects students and our most highly educated and trained individuals!

Breaking News!

• Among those affected:• more professional errors• impaired professionalism• reduced satisfaction for those they serve• increased job turnover and reduced hours• higher rates of depression and suicidal ideation• more motor vehicle crashes and near-misses• lower standardized test scores• …• the group affected most is also more likely to complete

suicides when affected.

What is this epidemic?• An infectious disease?

• Get the CDC involved ASAP!• Figure out the triggers and transmission patterns!• Develop effective prevention and treatment options!

• A chronic cardiovascular condition?• Rally the Surgeon General and the AMA!• Educate the public to prevent this problem!• Establish public health programs for support!

• A zombie apocalypse?

What is this epidemic?

BURNOUT

A Public Health Crisis!

Individual or system problem?

Burnout in U.S. alone:

>40,000 Medical Students

>60,000 Residents and Fellows

>490,000 Physicians

Plus other health care and biomedical science professionals

Objectives

• Discuss the scope of the problem of physician burnout.• Describe contributors to and consequences of physician burnout and

distress. • Discuss evidence-based methods to prevent burnout and promote

physician wellbeing.

Physician Distress: Key Drivers

• Excessive workload

• Inefficient work environment, inadequate support

• Problems with work-home integration

• Loss autonomy/flexibility/control

• Loss of values and meaning in work

The Evidence in Total• Systematic review on interventions for physician

burnout, commissioned by Arnold P. Gold Foundation Research Institute (West Lancet 2016):

• 15 RCT’s, 37 non-RCT’s• Results similar for RCT and non-RCT studies

The Evidence in Total• Emotional exhaustion (EE):

• -2.7 points, p<0.001• Rate of High EE: -14%, p<0.001

• Depersonalization (DP):• -0.6 points, p=0.01• Rate of High DP: -4%, p=0.04

• Overall Burnout Rate:• -10%, p<0.001

Benefits similar for individual-focused and structural interventions (but we need both)

The Evidence in Total• Individual-focused interventions:

• Meditation techniques• Stress management training, including MBSR• Communication skills training• Self-care workshops, exercise program• Small group curricula, Balint groups

• Community, connectedness, meaning

The Evidence in Total• Structural interventions:

• Duty Hour Requirements for trainees• Unclear but possibly negative impact on attendings

• Shorter attending rotations• Shorter resident shifts in ICU• Locally-developed practice interventions

Physician Well-Being: Approach Summary Individual Organizational

Workload

Work Efficiency/SupportWork-HomeIntegration/BalanceAutonomy/Flexibility/ControlMeaning/Values

Physician Well-Being: Approach Summary Individual Organizational

Workload Part-time status Productivity targetsDuty Hour RequirementsIntegrated career development

Work Efficiency/Support

Efficiency/Skills Training EMR (+/-?)Staff support

Work-HomeIntegration/Balance

Self-careMindfulness

Meeting schedulesOff-hours clinicsCurricula during work hoursFinancial support/counseling

Autonomy/Flexibility/Control

Stress management/ResiliencyMindfulnessEngagement

Physician engagement

Meaning/Values Positive psychologyReflection/self-awarenessMindfulnessSmall group approaches

Core valuesProtect time with patientsPromote communityWork/learning climate

Figure 3

Mayo Clinic Proceedings 2017 92, 129-146DOI: (10.1016/j.mayocp.2016.10.004) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017;92:129-46.

Recommendations• We have a professional obligation to act.

• Physician distress is a threat to our profession• It is unprofessional to allow this to continue

• Evolve definition of professionalism? (West 2007)• SHARED RESPONSIBILITY

• We must assess distress• Metric of institutional performance

• Part of the “dashboard”• Can be both anonymous/confidential and actionable

Recommendations• We need more and better studies to guide best

practices:• RCT’s• Valid metrics• Multi-site• Individual-focused AND structural/organizational approaches• Evaluate novel factors: work intensity/compression, clinical

block models, etc.

• Develop interventions targeted to address Five Drivers.

Recommendations• The toolkit for these issues will contain many different tools.• There is no one solution …• … but many approaches offer benefit!

Physician Distress: Key Drivers

• Excessive workload

• Inefficient environment, inadequate support

• Problems with work-home integration

• Loss autonomy/flexibility/control

• Loss of values and meaning in work

©2010 MFMER | slide-40

Thank You!• Comments/questions

• Email: west.colin@mayo.edu• Twitter: @ColinWestMDPhD